Resolution Claim Examiner

Responsibilities

• Proactively negotiate settlements for workers' compensation claims, ensuring fair and expedient resolutions that meet the needs of all parties involved.
• Conduct thorough investigations by engaging with insured representatives, claimants, and witnesses to gather critical information that supports settlement discussions.
• Analyze coverage issues and the applicability of benefits under relevant policies and statutes to facilitate informed negotiation outcomes.
• Establish and adjust reserves based on projected claim outcomes, ensuring alignment with corporate standards and settlement strategies.
• Collaborate closely with internal Managed Care and Medical resources to ensure that treatment plans and billing are managed effectively during the settlement process.
• Collect and evaluate essential documentation, including medical records and incident reports, to strengthen negotiation positions and expedite settlements.
• Utilize critical thinking and decision-making skills to assess claims and develop effective negotiation tactics aimed at achieving optimal settlement outcomes.
• Maintain clear, concise, and factual documentation in claims files and communications, supporting transparency throughout the settlement process.
• Manage time effectively, prioritizing negotiations and settlements in a fast-paced environment to meet deadlines and client expectations.
• Build and maintain strong relationships with customers, fostering their trust and confidence throughout the claims settlement process.

Qualifications

• Bachelor’s degree or equivalent experience.
• Minimum of 3 years of experience in handling and settling workers' compensation claims.
• Preferred experience in negotiating litigated or complex claims.
• State licensure as required.
• Proficiency with MS Office Suite and claims management software.
• Strong negotiation, investigation, and evaluation skills specific to workers' compensation claims.
• In-depth knowledge of workers' compensation laws and insurance practices.
• Ability to travel, as required for some positions.

Preferred Qualifications

• Multijurisdictional experience may be required.
• CPCU, ARM, AIC, or other relevant claims certifications are preferred.